CAMPERSHIP REQUEST FORM An electronic version of this form can also be completed online at www.nccoastalpines.org on our camps page. All applications are strictly confidential. If you are applying for the Sue “Skipper” Csorba award, simply complete the financial assistance application. Csorba scholarship award are due by January 17, 2020. All other applications for resident camp assistance are due by April 1, 2020. Please complete the entire form (print in BLACK ink) and return it with the registration form and required deposit to: Girl Scouts – North Carolina Coastal Pines Attn: Campership 6901 Pinecrest Road, Raleigh, NC 27613
Please check if you are applying for the Csorba Award.
Camp attending:
Camp Mary Atkinson
Camp Graham
Please check if you have already registered and paid the deposit (not required for Csorba award)
Camp Hardee
Adventure Trip
Name of Camp Session and Date Have you attended camp before?
Yes
No
Girl’s Name Age Grade Mailing Address City/State/ZIP Home Phone
Cell Phone
County/Area
Name of Parents/Caregivers Parent One Occupation
Parent Two Occupation
Troop Please list all volunteer positions held by camper’s parents/guardians
Basic Information A. Total number of family members (include individual making request): B. Total family income
under $15,000
$50,000 to $74,999
$15,000 to $24,999
$75,000 to $99,999
$25,000 to $34,999
$100,000 to $149,999
C. Have you received financial assistance from this council before?
If yes, name of event/camp:
Amount and year received:
D. Do you owe money to Girl Scouts–North Carolina Coastal Pines?
over $150,000
Yes
No
Yes
No
E. Is anyone in the immediate family active duty military, reservist, retired, or disabled veteran?
$35,000 to $49,999
Yes
No
List family member
F. Did your camper participate in the 2020 Girl Scout Cookie Program? G. Did your camper participate in the 2019 Fall Product Program?
Yes
Yes
No
No
H. Describe the reason for your request and how you expect your child to benefit from a camping experience.
(You may continue on a separate sheet of paper, if necessary.)
Each event and camp has a deposit that must be paid before a financial assistance request will be considered. There is a limit of one campership to one session per girl, not to exceed $200. There is a $100 non-refundable deposit per session. Camp/Event Fee $ Deposit Amount Paid $ 100
$0.00 CSORBA App.
Amount you will contribute toward this opportunity $ AMOUNT OF FINANCIAL ASSISTANCE REQUESTED $ Parent/Guardian Signature Date
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